Business System Analyst - Medicare Operations

Category: Business Analysis (functional and technical)

Main location: United States, Massachusetts, Canton

Position ID:J0526-1351

Employment Type: Full Time

Position Description:

CGI is seeking a Medicare Operations Business Analyst who will serve as a subject matter expert and process driver within a healthcare payer organization, supporting the end-to-end lifecycle of Medicare Advantage and Part D programs. This role bridges CMS regulatory requirements with operational delivery - translating complex compliance mandates into actionable workflows, member communications, and system requirements. The ideal candidate combines deep knowledge of Medicare regulations with strong analytical skills and the ability to partner across clinical, IT, compliance, and vendor teams.

This role must be performed from the client site in Canton, MA (Hybrid)

Your future duties and responsibilities:

CMS Compliance & Regulatory Operations
. Serve as a business-side subject matter expert on CMS regulations, including the Medicare Managed Care Manual, Part D Policy and Procedures, and annual Call Letter requirements.
. Monitor and interpret CMS guidance updates, translating regulatory changes into actionable business requirements for operations and IT teams.
. Coordinate internal CMS audit readiness activities including HPMS submissions, mock audits, and corrective action plan (CAP) tracking.
. Partner with compliance and legal teams to ensure all operational processes meet CMS standards and timelines.
Part D Letters & Member Communications
. Manage the business requirements, content governance, and quality assurance for all Medicare Part D member-facing correspondence.
. Own the lifecycle of Coverage Determination letters, Formulary Exception notices, Redetermination letters, Transition Fill notices, and Low-Income Subsidy (LIS/Extra Help) communications.
. Ensure all letters comply with CMS model language requirements, plain language standards, and culturally and linguistically appropriate services (CLAS) mandates.
. Maintain a letter inventory and version-control repository; track CMS-required revision cycles and model language updates.
Enrollment & Eligibility Operations
. Support Medicare enrollment operations including Initial Enrollment, Annual Enrollment Period (AEP), Special Enrollment Period (SEP), and disenrollment processing.
. Analyze enrollment data to identify trends, discrepancies, and process improvement opportunities.
. Assist in resolution of member eligibility issues, retroactive enrollment adjustments, and CMS discrepancy reports.
Coverage Determinations & Appeals
. Document and maintain business process workflows for Part D coverage determinations, exceptions, appeals, and grievances (CDAG).
. Ensure timeliness and compliance with CMS-required decision timeframes.
. Partner with the pharmacy and clinical teams on formulary management, step therapy, and prior authorization criteria.
Business Analysis & Process Improvement
. Elicit, document, and validate business requirements for Medicare-related system enhancements and operational projects.
. Develop process maps, workflow diagrams, use cases, user stories, and functional specifications.
. Conduct gap analyses between current-state operations and CMS requirements or best practices.
. Lead and facilitate cross-functional working groups, stakeholder reviews, and UAT planning.
. Produce dashboards, KPI reports, and trend analyses to support operational and executive decision-making.
. Apply continuous improvement methodologies (Lean, Six Sigma) to drive efficiency gains in Medicare operations.

Required qualifications to be successful in this role:
. 7+ years of experience in healthcare payer operations with a focus on Medicare Advantage and/or Part D.
. Demonstrated knowledge of CMS regulations, the Medicare Managed Care Manual, and Part D Policy and Procedures.
. Hands-on experience with Part D member communications including Coverage Determination, Formulary Exception, and Appeal letters.
. Experience supporting enrollment operations and CMS transaction processing (834 files, HPMS).
. Proficiency with business analysis tools: process mapping (Visio, Lucidchart), requirements documentation, and UAT facilitation.
. Strong data analysis skills; proficiency in Excel;
. Excellent written and verbal communication skills with the ability to translate regulatory language for operational audiences.

. Bachelor's degree in health administration, Business, Public Health, or a related field.

Other Information:
CGI is required by law in some jurisdictions to include a reasonable estimate of the compensation range for this role. The determination of this range includes various factors not limited to skill set, level, experience, relevant training, and licensure and certifications. To support the ability to reward for merit-based performance, CGI typically does not hire individuals at or near the top of the range for their role. Compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range for this role in the U.S. is $80,600.00 - $172,400.00.

CGI's benefits are offered to eligible professionals on their first day of employment to include:
. Competitive compensation
. Comprehensive insurance options
. Matching contributions through the 401(k) plan and the share purchase plan
. Paid time off for vacation, holidays, and sick time
. Paid parental leave
. Learning opportunities and tuition assistance
. Wellness and Well-being programs

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Skills:

• Data Analysis
• ETL
• Health Care Analytics
• Health Care Payers
• Oracle
• Problem Management
• Requirement Management
• SQL
• User acceptance testing